Write your appeal letter

Answer what you can from your denial letter. You get an appeal letter and a note to your doctor, ready to print or copy. Anything you leave out stays as a marked blank.

Nothing you type here is sent or saved. The page does the work inside your browser, and its security policy blocks it from sending data anywhere. That also means it cannot remember your letter, so copy or print it before you close the tab.

The denial

What kind of coverage is it?

Date printed on the denial letter

What reason does the letter give?

Where are you in the process?

Waiting could seriously harm the patient's health. Ask for a fast (expedited) decision.

Ask whether an algorithm or software tool was used in the decision.

You and the plan

I am the patient

I am helping the patient (a parent, spouse, child or friend)

Your full name

Phone

Patient's date of birthOnly used in the note to the doctor

Your mailing address

Insurance company or plan name

Member ID

Claim or reference numberFrom the denial letter or Explanation of Benefits

Where appeals goThe appeals address or fax number in the denial letter, not the general claims address

What happened

What was denied?For example: an MRI of the lower back, 14 more days of skilled nursing care, the drug Humira

Doctor who ordered itAs you want it written, for example Dr. Maria Lopez

Date of the service or request

The insurer's reason, in their exact wordsCopy it from the letter, including any criteria or policy they name

Why the decision is wrongAnswer their reason with facts. Two to four short paragraphs is enough. The list above shows what appeals like this usually cover.

The doctor's letter of medical necessity

I will send it separately

It is enclosed with this appeal

What else you are enclosingOne per line. For example: denial letter, office notes from March, MRI report

Write your appeal letter

What appeals like this usually cover

What people usually attach

Your appeal letter

Sending it

A note to your doctor

What the doctor's letter should cover